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Mariana Gomez MRN-100214 · born 2025-01-21 ✦ AI Ask ✦ AI Ambient note Chart

Claim CLM-2026002004

Mariana Gomez MRN-100214 Payer Blue Cross Blue Shield Service Dec 17, 2025 Status paid
$51.54
billed
$36.08
allowed
$0.00
paid
$36.08
patient responsibility

Adjudication lines

ServiceCodeBilled Paid
Amoxicillin 500 MG Oral Tablet308192 $0.00 $0.00
Therapeutic injection/administration96372 $35.47 $24.83